Masters of the Ordinary

By this past March, it had been 4½ grueling years since 9/11. Across America, emergency plans had long since been redrawn, training amped up, billions spent on equipment and gear, enough CO2 expended on need-to-be-ready rhetoric to burn a Texas-size hole in the ozone. And in New York City, where the events of that day so famously touched off this national scramble for preparedness, they held a simulation.

The exercise, called Trifecta, posited a bomb containing highly toxic arsenic trichloride exploding on a freight train in a Queens rail yard just as it passed a passenger train heading in the opposite direction. It involved more than two dozen agencies and around 1,500 responding personnel, whose priorities included freeing victims, triaging and treating the injured and evacuating unhurt passengers. For this they were to use the Big Apple's year-old Citywide Incident Management System (CIMS).

The fire department was the first to respond; police, as CIMS dictates, then took the lead and established a unified command. EMS was...where, exactly? Outside looking in. Try to control your surprise.

"We could have probably done a slightly better job in handling the persons who were injured," the city's commissioner of emergency management, Joseph Bruno, acknowledged afterward. "We saw a real lag in getting people out of the area. I was critical of how long people were having to wait for EMS to come in."

Part of the delay, the New York Times reported, was due to participants' reluctance to move victims without more information about what chemical threat they were facing and how bad it was. A possible solution, Bruno suggested, might be to create triage areas within the restricted zone, "so that EMS could work on these folks as quickly as possible."

Another problem was that arriving responders, particularly from the Department of Environmental Protection, created a logjam of hastily parked vehicles that-much as happened on 9/11-hindered coming and going from the scene. "If there were failings," Bruno noted, "that was one of them."

The New Ideal
The Trifecta exercise wasn't a disaster unto itself, and it didn't expose anything scandalous. But it did illustrate just how elusive a concept homeland security, as it applies to the emergency services-and particularly to EMS-can be, and just how difficult it really is to recreate (or, in some instances, create) a nation's entire emergency response framework in a few short years.

America's new ideal-a seamless battery of well-trained, well-equipped and well-integrated forces that can rely on well-tested plans to respond, promptly and properly, to any hazard, anytime, anywhere-is asking a lot. And that's worth remembering in September 2006, which represents the fifth anniversary of the attacks that started it all.

It's worth remembering when, as happened in Louisiana in May, a mock evacuation that's part of a hurricane preparedness drill is canceled because no one can determine who has jurisdiction over a FEMA trailer park full of Katrina refugees.

It's worth remembering when an audit scorches a major city's (San Francisco's) office of emergency services, as it did that same month, for failing to complete its disaster plans, including one as central as how to handle an earthquake (this coming, ironically, 100 years after the city's most famous temblor).

It's worth remembering when the Department of Homeland Security's National Asset Database-a listing of potential terrorist targets that helps federal officials determine how to disperse grant funds to the states-identifies more sites in Indiana (8,591) than in New York (5,687) or California (3,212).

And it's worth remembering when that now-familiar 4% figure is brought up (4% being the percentage of the $3.38 billion distributed by the Department of Homeland Security for emergency preparedness that went to EMS in 2002-03).

Have there been screwups and inefficiencies? You betcha. Has EMS gotten everything it needs and deserves? No way. But if we're going to assess the Big Picture five years on, it's the context with which we must begin. America faced a monumental challenge that September 12. Five years isn't a lot of time to get all the answers right.

I'll Have The Dessert
OK, so homeland security is hard. Should that justify something as shameful as 4%? It's difficult to say it should.

"From a true EMS standpoint, the guys who provide out-of-hospital emergency medical response and care and transport-they've gotten little or no support, because there's nobody at the big table," says Gregg Lord, a senior policy analyst for the George Washington University's Homeland Security Policy Institute. "The fire services that do EMS have gotten some stuff, but it's almost always through the fire side. Why isn't EMS getting the same? If you look at workload and numbers of responses, you could argue that we should probably get 60% more, because we do 60% more work. But we've gotten little or none of that."

The "whys" behind this aren't a mystery: EMS simply isn't on decision-makers' radar screens. It lacks the loud, coherent voice and well-developed political presence of the fire service and law enforcement. So when the time comes to compete for limited emergency-services dollars, it's out of the limelight, out of the debate and, as in Trifecta, relegated to the land of afterthought.

Five years after 9/11, that's not only the landscape in DC, it's repeated in an alarming number of state capitols.

"In some states, EMS has had difficulty getting to the negotiating table to get funding," says Robert Bass, MD, president of the National Association of State EMS Officials and executive director of the Maryland Institute for Emergency Medical Services Systems. "It's a real issue. Homeland Security funds come to the state level and are distributed there, and we've seen data that 4% or less of the funding coming out of DHS for states, at least that we can identify, is going to EMS. We've talked to DHS about this, and Congress has expressed concern. The trend does not seem to have changed."

So here we are, David fighting Goliaths for a bigger slice of the emergency services pie-a conflict that, biblical lore notwithstanding, tends to end with David getting squashed.

Ideally, we wouldn't have to compete. Ideally, we'd get our own dessert. Ideally, no one goes to bed hungry.

"We shouldn't be poaching the fire service's pie," says Lord, retired operations chief for Worcester EMS in Massachusetts. "I have no issue with what they're able to get out of Congress every year under the AFG [Assistance to Firefighters grant program] or the SAFER Act-that's great. But from a preparedness standpoint, EMS in the big cities around this country is busier now than it's ever been. Demand continues to grow, but we have no resources, no assets. Our EMS systems have no capacity. They can't keep up with what comes through the 9-1-1 chute, never mind extraordinary events.

"We want our own pie!"
Snapshot of a Solution: CommunicationsOffice Won't Negate Need for Comms Plan
By a vote of 414-2, the U.S. House in late July passed legislation that would establish an Office of Emergency Communications within the Department of Homeland Security and require local responders receiving federal grant funds to purchase equipment that meets national standards for interoperability.

While Democrats criticized the bill for not providing funds to help communities upgrade, some may not even need new equipment, says National Emergency Management Association president Bruce Baughman, director of emergency management for the state of Alabama. What they need is a plan.

"How do you know you have interoperability issues unless you've done a comprehensive communications plan?" Baughman asks. "Everybody's always looking to buy new systems when existing systems may meet their requirements. With everything from the public switch network to satellite telephones to 800 MHz to UHF and VHF, interoperability issues often can be taken care of through a switching device. We have ACU-1000s [a well-known switching device from Raytheon JPS Communications] in our 9-1-1 centers, and we've tapped into other types of systems, like wireless priority service for our cell phones. A lot of people don't even know about that. We've looked at our requirements and at existing technology and, rather than buying new systems, tried to look at ways of integrating that existing technology. The only thing we've had to buy is the ACU-1000s."

Better Than Nothing
Certainly, there's been no shortage of prose devoted to chronicling EMS's problems of late. Among this verbiage was a report, Emergency Medical Services: The Forgotten First Responder, released in 2005 by New York University's Center for Catastrophe Preparedness and Response. From it, we learned the following:

• More than half the nation's EMTs and paramedics have received less than an hour of training in dealing with chemical and biological agents and explosives since 9/11; 20% have received none.
• In the year preceding the report, fewer than a third of EMTs and medics participated in drills simulating chem, bio or radiological attacks.
• In 25 states, the percentage of EMTs/medics with adequate equipment to respond to a chem/bio attack was 50% or less.
• 60% of ambulance services received no federal funds to help them buy preparedness equipment.

If you're a glass-half-full type, that probably does represent some nominal progress in a primary area of concern that emerged from 9/11. While not where they should be, things are probably-inconsistently, fitfully, here and there-a bit better.

Turns out that's a common theme when you start asking how far EMS has come since that terrible day.

"I think we're making progress," says Jerry Overton, executive director of the Richmond (VA) Ambulance Authority and past president of the American Ambulance Association, who was part of the working groups behind the Institute of Medicine's Emergency Medical Services at the Crossroads report released in June (see last month's cover story). "Are we totally there yet? No-clearly we have a ways to go. We're making progress in areas like training and communications interoperability, but there are still gaps. We need to keep working to fill those gaps."

Let's talk about that progress. On the plus side of the ledger, start with basic recognition of the range of threats that exist out there (terrorism and WMDs, in addition to natural disasters, accidents, pandemics and day-to-day overload) and the scope of how they might manifest. When it comes to disasters and responses, Americans undoubtedly think bigger now.

"I think folks have recognized that we really haven't paid enough attention to the issue of disaster preparedness in the past," says Jerry Johnston, incoming president of the National Association of EMTs and EMS director at the Henry County Health Center in Mt. Pleasant, IA. "I live in rural Iowa, for instance, and we don't perceive ourselves as being a terrorist target. Yet, my community has 30-some trains that come through every day, carrying any number of dangerous chemicals, that could derail. What we really have recoginized is that we need to be better prepared. We were not as prepared as we thought we were. Even on the local level, we need to provide more training and funding and resources to be able to handle those types of issues."

Other issues highlighted by 9/11 can be broadly grouped around the concept of integration. This overhangs things like communications and data, mutual aid, the continuum of care, training and much more. That incident you now know could be much bigger than you'd imagined will necessitate your working alongside, talking to, exchanging data with and training beforehand with not only your local police and fire colleagues, but your neighbors who can contribute resources, the hospital and public-health personnel who will have roles to play, state and federal officials and a dizzying range of others.

Things here are somewhat better. Many jurisdictions have improved their communications interoperability, beefed up their mutual aid agreements and taken a broader approach to training. The necessary relationships aren't all functional and seamless yet. But across the board, there's more attention being paid to them.

"The events of 9/11 brought to the forefront some of the difficulties different agencies have in cooperating, coordinating and integrating their functions," says Bill Jermyn, DO, FACEP, EMS medical director for the Missouri Department of Health and Senior Services and chair of the American College of Emergency Physicians' EMS Committee. "There has been some progress there. I don't think you'll find anybody who'll tell you we're where we should be with it, but at least we're having the discussions now. I think people understand the importance of that cooperation and integration and coordination."

"I'm impressed, at least in my state, in terms of the dialogue between the state and local agencies," says Bass, whose state was recognized in the IOM report for the advances it's made in these areas (see The Maryland Model). "Coordination between EMS and public health has improved. But we want to continue to improve. That's the nature of preparedness: You're always preparing."

Recognition of the need to function compatibly at major-incident scenes has yielded an emphasis on tools of standardization such as ICS and the National Incident Management System (NIMS). The frameworks under which emergency responders work together have been articulated and formalized. This may be the greatest lasting legacy of 9/11: In the future, everyone responding to a major incident will speak the same language and work from the same playbook.

"What failed on 9/11 wasn't the emergency response side," says Bruce Baughman, who was FEMA's director of operations for response efforts at both the World Trade Center and the Pentagon in 2001 and is now president of the National Emergency Management Association. "From the emergency response perspective, I think things worked fairly well, especially at the Pentagon. There were some hiccups, obviously, in New York that I think were related to the fact that they had not yet fully embraced ICS. Things could have run better had ICS been in place at that time. And the advent of NIMS and ICS across the country, via the mandate from DHS, I think has been a plus."

Snapshot of a Solution: IOM Model Systems
The Maryland Model
While the Institute of Medicine's long-awaited Emergency Medical Services at the Crossroads report painted a bleak overall picture of EMS today, it did cite several model systems its authors believed exemplify the types of coordination, regionalization and accountability EMS needs. One of these is Maryland's EMS and trauma system.

Though state EMS and 9-1-1 services are operated locally, Maryland providers adhere to statewide triage and treatment protocols that facilitate care at such regional facilities as trauma, neurotrauma, perinatal and burn centers. A new stroke protocol and designation of stroke centers will bring the same structure to stroke care.

Statewide communications are centered at a Baltimore hub that links all components of emergency medical care-EMS, hospitals, trauma and specialty centers, and dispatch-and allows field providers fast access to online experts, as well as their public-safety and public-health counterparts. A common statewide ePCR form standardizes data collection to allow analysis and quality improvement.

The state's County Hospital Alert Tracking System monitors hospital statuses and helps direct ambulances to facilities that can receive them, as well as charting trends in diversion.

These data-collection efforts precede recent disasters. State leaders were working even before 9/11 to become compliant with the requirements of the National EMS Information System (NEMSIS).

"The bottom line is, day to day, we need more data on what we do," says Robert Bass, MD, executive director of the Maryland Institute for EMS Systems. "To get that data, you have to have the system and infrastructure and standardized definitions. When we go to meetings now, a lot of our brother disciplines are blown away when they see the work we've done with respect to our information systems and data definitions."

A Year After Katrina
So what happened in the Gulf area?
As long as we're recognizing anniversaries, it's worth talking about Katrina, now a year past. There have been numerous postmortems chronicling what went awry at the various levels of that response (see Katrina: What Went Wrong?). One theme that emerges is that some basic requirements of ICS/NIMS weren't met.

"The main thing Katrina pointed out goes back to the lack of a unified command," says Baughman, who is also Alabama's director of emergency management. "That was the biggest shortfall. [Former FEMA director] Mike Brown testified that he saw no evidence of a unified command, and I think he's exactly right."

DHS Inspector General Richard Skinner reached the same conclusion in his review of March 2006, noting that "Louisiana had great difficulty establishing an integrated command structure, and never fully achieved a unified command with FEMA."

Skinner also noted that NIMS and the National Response Plan (NRP) were still essentially new, and that everyone was still adjusting to them when the storm hit. While ICS isn't new to certain states, federal entities like DHS and FEMA have only more recently bought in, necessitating a transition curve.

Even before NIMS, "Many of the states were using ICS," says Baughman. "Who wasn't using ICS was the federal side of the house. The Forest Service, the Park Service and those in the wildland fire arena were using it-it was really DHS and FEMA [that weren't]. Even when I was with FEMA, we were using ICS, but it wasn't fully embraced. I'm seeing more of that now. Even DoD, while not embracing it for day-to-day use, is sending their people to training so that when they have to interface during military support of civilian authorities, they have a better understanding of ICS."

White House adviser Frances Townsend addressed this point in her February 2006 report, The Federal Response to Hurricane Katrina: Lessons Learned. "All federal departments and agencies," Townsend determined, "should align their response structures to NIMS. In accordance with this alignment, the entire federal response structure should be NIMS-based, reporting through one unified command using the same terminology and basic organizational structure."

Meanwhile, local public-safety capabilities were shattered, throwing the entire planned hierarchy of response into disarray. Wrote Townsend: "State and local authorities understood the devastation was serious but, due to the destruction of infrastructure and response capabilities, lacked the ability to communicate with each other and coordinate a response. Federal officials struggled to perform responsibilities generally conducted by state and local authorities, such as the rescue of citizens stranded by the rising floodwaters, provision of law enforcement, and evacuation of the remaining population of New Orleans, all without the benefit of prior planning or a functioning state/local incident command structure to guide their efforts."

The response system we've built, she concluded, "clearly has structural flaws for addressing catastrophic events."

Snapshot of a Solution: Lessons Learned
Katrina: What Went Wrong?
A number of high-level reports from within the federal government have assessed what went wrong in the response to Hurricane Katrina in New Orleans. Among the recommended reading:

• A Failure of Initiative: The Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, by the U.S. House of Representatives' committee of the same name
  https://katrina.house.gov/
• The Federal Response to Hurricane Katrina: Lessons Learned, by Frances Frago Townsend, Assistant to the President for Homeland Security and Counterterrorism
  www.whitehouse.gov/reports/katrina-lessons-learned/letter.html
• Hurricane Katrina: A Nation Still Unprepared, by the Senate Committee on Homeland Security and Governmental Affairs
  https://hsgac.senate.gov/index.cfm?Fuseaction=Links.KatAdd
• A Performance Review of FEMA's Disaster Management Activities in Response to Hurricane Katrina, by Department of Homeland Security Inspector General Richard Skinner
  www.hsdl.org/hslog/?q=node/2859

Pressing Engagements
The issues involved in the Katrina debacle are too varied and complex to explore fully here, so let's boil it down to what you, the local-level chief and responder, need to take from it all.

In the initial stages of a major disaster, you're likely to be on your own. If federal resources (DMATs, USAR teams, etc.) can arrive quickly enough to address life-safety issues, great. But you'd better have capabilities of your own and plans in place to get more-through mutual aid, if need be, or by arranging additional resources through appropriate state channels (see Help From Outside the Federal Loop, and What You Want, What You'll Get).

"One thing that Katrina made clear," says Johnston, "is that all planning is local. The federal government, through a variety of sources, can certainly assist in providing resources, grants and the funding and training we need, but ultimately, it's everyone's responsibility locally, with the resources they have, to train and plan for these events at the local level."

Adds Baughman: "Emergency management, in conjunction with EMS, ought to be taking a look at what kind of shortfalls they're going to have, and what resources are available locally, through various state agencies and through statewide mutual aid."

In Alabama's case, that's meant recognizing that in a major disaster, demand for EMS in the state will exceed supply. So it already has a request on file for DMATs to augment local capabilities.

The bottom line, though, is that while some such assets are available from the federal level, the burdens of planning and initial response are primarily, irrevocably local. And sufficient capability is a local obligation.

"You build basic capacity at the local level," says Paul Maniscalco, director of GWU's Emergency Services Management Program and past president of the NAEMT. "That's where the change has to start. So then the question becomes, how much interest do the local governments have? And how much interest do the local EMTs and paramedics have in engaging those politicians, getting them to the table, showing them that they need to value the mission and resource the operation and respect the people doing the work? If you want to be a leader, it requires that you follow through. You have to engage."

Snapshot of a Solution: EMAC
Help From Outside the Federal Loop
Five days after Hurricane Katrina struck, Louisiana's Plaquemines Parish got its first outside help: a task force from the New Mexico National Guard. It hadn't come as part of any federal effort; it was loaned directly from state to state under the Emergency Management Assistance Compact (EMAC).

Arkansas tried to send help to its southern neighbor via FEMA, but, Governor Mike Huckabee told the National Journal, his officials kept getting conflicting information. The state eventually dispatched Guard troops, state police and rescue boat crews-also through EMAC.

Throughout the stricken Gulf region in 2005, the quickest help often came from outside the federal loop. Much of it resulted from EMAC, an agreement by which states commit to assist each other in times of disaster. EMAC is operated by the National Emergency Management Association (NEMA) and isn't part of FEMA or any federal response structure.

With the structural problems hampering FEMA in such situations-among other problems, it can't issue orders to other federal agencies or to the states; it can only ask for their assets and resources-compacts like EMAC could represent a faster and easier way for states in need to get assistance.

"Over 67,000 personnel were mobilized under EMAC for Katrina," says NEMA president Bruce Baughman, director of emergency management for Alabama. "That was far more than what was mobilized under the federal government."

For more, see www.emacweb.org.

Life In No-Man's Land
That's always what we come back to, isn't it? Get active, harangue your local leaders and elected officials, and make them notice you and help you. It feels like a bit of a copout, because we all know how hard that is for most EMSers, but there's really no way around it. And the higher you go in your organization, the more it falls to you.

"The guys in the trucks," notes Lord, "are too busy trying to figure out how to pay their mortgage. They don't have time to go to their city council meetings, because they're working two jobs. But the directors, the chiefs, the administrators, they bear a lot of that responsibility, once they obtain that level, to become engaged with their local politicians, their mayors, their city councils, their county commissioners, to advocate for the industry and the people. And I don't know that you see that as much as you should."

And this brings us back around to the idea of a lead federal agency. What lobbying and PR could take years to achieve incrementally, perhaps a U.S. EMS Administration could bestow much quicker.

The notion still enjoys widespread support. Nearly every source contacted for this article came back to it. The IOM's Crossroads report reignited the crusade with a call for such an entity in the Department of Health and Human Services; last year, in a high-profile paper of its own, the HSPI argued for one in the Department of Homeland Security. Truth be told, most EMS advocates seem flexible about the location of such a body. It's not where it's created; it's that it's created.

"NAEMT's position is that there needs to be an EMS office, period," says Johnston. "We don't say where it should be; we just believe there needs to be one. My personal view is that until we have a federal EMS office that's properly funded and empowered, we're going to continue to struggle, not only from a funding standpoint, but in dealing with legislative issues as well (although we've made some strides there in the last couple of years)."

"The emergency medical care system really is on that interface between public health, public safety and healthcare," says Bass. "So we're sort of in a no-man's land in the sense that we're a hybrid entity. And that's particularly true for EMS. In the public-safety community, we're viewed as healthcare providers, and in the healthcare community, we're sometimes viewed as public-safety providers. So you need a federal agency as one lead entity that can bring all of these components together. Because if we can't pull it together at the federal level, it's going to make it even more difficult at the state and local levels."

A lead agency, proponents say, could not only ensure reliable funding for EMS needs, it could apply a degree of standardization to things like training, scopes of practice and how EMS systems tie into the larger continuum of healthcare. Capacity may primarily be local, but that lack of standardization-a true hallmark of modern American EMS-makes helping it difficult.

"Look at the history of the U.S. Fire Administration," says Lord. "The fire service would pretty much be a mishmash of provider models, with no standards, if they hadn't created the USFA. They worked in conjunction with a lot of the stakeholders, they developed federal policy, and they pushed it down, tying it to money. 'If you want the money, you have to do this.' And lo and behold, now you have standards across the spectrum."

Right now, of course, federal involvement in EMS is scattered and weak. The Federal Interagency Committee on EMS, revamped and strengthened by legislation passed last year, meets for a few hours each quarter-hardly sufficient to tackle the industry's problems. And the EMS Office within NHTSA, putatively the home of EMS in the federal government, remains small and limited in mission. They declined to make someone available to comment for this article.

Snapshot of a Solution: Resource Typing
What You Want, What You'll Get
Emergency managers and other officials involved in disaster response have long recognized the value of standard resource typing. When you ask for assets from another community or state, they need to know what you're expecting, and you need to know what you'll get. That's more important than ever these days, with mutual aid and assistance from afar at a premium.

"I know the Gulf states have been working feverishly to address typing and credentialing issues, so there's a better understanding of what states are requesting in terms of support and what sending states are supposed to put together," says Maryland EMS director Robert Bass, MD, president of the National Association of State EMS Officials. "There's been a lot of progress in those areas."

Alabama, for one, started its typing efforts three years ago, says its director of emergency management, Bruce Baughman.

"If I ask for a heavy-rescue team anywhere in the state," Baughman says, "each one of those teams are staffed, equipped and trained the same."

Federally, officials from the NIMS Integration Center offer definitions for a number of EMS and emergency management resources at www.resourcetyping.com. If you're uncertain exactly what constitutes an ambulance strike team or a rapid needs assessment team, they'll tell you.

Mastering The Ordinary
Really, for EMS, the fifth anniversary of 9/11 isn't about responding to landmark disasters. It's about the mundane-surviving day by day. You have to master the ordinary before you can master the extraordinary. Right now, that's plenty challenge enough.

"You have to have a functional day-to-day system that's not hanging on by its fingernails before you can start talking about what you're going to do in a disaster," says Jermyn. "Our resources right now within the emergency medical care system are limited, and it's difficult to pull a significant amount and send them somewhere else. If you can't even take care of what you have at home, there's no way you can send off resources to another part of the nation."

"Preparedness is built on the foundation of what you do on a day-to-day basis," agrees Bass. "We have a lot of concerns about EMS-and about the whole emergency care system-on a day-to-day basis. Our systems seem to be increasingly saturated. Surge capacity is an area where we've probably declined since 9/11. In terms of healthcare for the community, the emergency care system is the safety net, and that safety net is stretched to the point of breaking. And that's a very shaky foundation to try to build an emergency response upon."

"The catastrophic events are needed to begin to raise the awareness of what we're doing on an everyday basis," says Overton. "We need to make sure the public understands that we are interacting with them more and more, not just in catastrophic events, but for their cardiac arrests, for their chest pains, for their respiratory distress. Expectations of EMS keep getting higher, and if we don't get the proper funding for what we're doing, we could find ourselves dealing with catastrophic events every day."

Snapshot of a Solution: Fixing FEMA
Sending In the 'A' Team
FEMA took such a bad rap a year ago that its director, Mike Brown, was ignominiously dismissed a few days after Katrina. Obviously, though, the problems went beyond one man.

"I think in the case of Louisiana, rather than sending a pickup team down there to man that disaster, I'd have sent one of FEMA's national teams," says National Emergency Management Association president Bruce Baughman, a FEMA veteran who directed deployment of emergency personnel at the Pentagon and World Trade Center on 9/11. "When I was there, the teams were composed of up to 125 people who were trained to handle catastrophic disasters. That didn't happen during Katrina; consequently, the team that was sent in there probably wasn't the best and the brightest. And I think it showed."

DHS Secretary Michael Chertoff seems to have gotten the message: Among the changes he's making to FEMA is the development of a core of highly trained staffers to lead responses to disasters. As many as 1,500 new employees, the AP reported, will be hired for year-round disaster coordination.

Also planned: reconnaissance teams to funnel better information from disaster scenes back to DHS officials, and a streamlined logistics management system to better track equipment and materials.

It may or may not be enough. Some in Congress remain ready to overhaul the agency, remove it from DHS or disband it entirely.

"FEMA is discredited, demoralized and dysfunctional-it is beyond repair," Sen. Susan Collins (R-ME), chair of the Senate Homeland Security and Governmental Affairs Committee, said in April. "Just tweaking the organizational chart will not solve the problem."

Snapshot of a Solution: Smart Politics
Play the Game, But Play Smart
Play the game, we're always telling you. Get involved in the political process and let your decision-makers know what EMS needs.

Too many in EMS, conversely, let the politicians play them.

"If a politician shows up on your doorstep and you haven't done your homework on who your friends are," says NAEMT past president Paul Maniscalco, director of the Emergency Services Management Program at the George Washington University, "and you let them take pictures with you that are going to turn up in some campaign flyer, then you're a fool.

"We've found photos of EMS crews with politicians on some politicians' election websites, and when we've looked at those politicians' voting records, they've consistently voted against EMS interests. But the EMS people allowed them to come into their house, take photos with them and produce campaign literature telling the public, 'Look-I'm Mr. Public Safety!' That has to stop. We have to be more savvy. We have to be sophisticated in what we're doing and how we're doing it."